SCOPE OF PRACTICE
Otolaryngology offers a unique scope of practice compared to many other specialties lending practitioners exceptional flexibility within the field -- from 2 minute ear tubes to a 12 hour composite resection and free flap reconstruction, we do it all. Otolaryngology is one of the few surgical subspecialties without a true medical counterpart (orthopedic surgery with sports medicine; neurosurgery with neurology and so on…). Not only does this increase the number of conditions the practitioner is comfortable managing, it also permits more career flexibility allowing the otolaryngologist to tailor his/her practice toward either surgical or medical involvement. This unique mix has led many prominent otolaryngologists to assume positions of leaderships within their insitutions.
Unlike other specialties, the realm of the otolaryngologist is not defined by a “body system” (as orthopedics is to bones, urology is to the urogenital system etc…) but instead is uniquely defined by an anatomic region. Because of this, the field boasts a range of subspecialty areas covering very different organ systems, each requiring a diverse surgical skill set (laser surgery, drilling, microsurgery, endoscopy, gross dissection, etc). Below is a breakdown of some of the subspecialties within Otolaryngology-Head and Neck Surgery:
Head and neck – resection and reconstruction of tumors of the head and neck, including, but not limited to, cervical lymphadenectomy (neck dissection) and resection of tumors of the skull base, aerodigestive tract, and thyroid. There are a number of options for reconstruction, ranging from skin grafts to microvascular free flaps.
Facial plastics – cosmetic and reconstructive procedures of the head and neck, including, but not limited to, rhinoplasty, facelifts, browlifts, blepharoplasties, and Mohs reconstructions.
Laryngology – evaluation and medical/surgical management of the larynx, including, but not limited to, phonosurgery, endoscopic treatment of laryngeal tumors, and even management of the professional voice.
Otology/Neurotology – management of disorders of the ear and lateral skull base including, but not limited to, middle ear and mastoid surgery, stapedotomy, tympanoplasty, labyrinthectomy, cochlear implantation, and acoustic neuroma (vestibular schwannoma) surgery.
Pediatric – management of otolaryngology disorders in children including but not limited to endoscopic sinus surgery, airway endoscopy, middle ear disease, cochlear implantation, microtia and aural atresia, cleft lip and palate (at some institutions), laryngotracheal reconstruction, vascular malformations, head and neck tumors, and of course, lots of tubes and tonsils.
Rhinology – management of disorders of the nasal cavity and paranasal sinuses, including endoscopic sinus surgery, endoscopic management of paranasal and anterior skull base tumors, CSF leaks, orbital tumors, etc.
Depending on the area of specialty, otolaryngologists care for the entire spectrum of patient demographics: from the neonate with congenital airway disease to the septuagint with hearing loss, both males and females alike. “No one is immune to seeing the otolaryngologist”.
It has become cliché to say, but the head and neck does in fact offer some of the most beautiful and complex anatomy in the body. There is likely no other more surgically challenging area of the human body with respect to functional and aesthetic concerns than the head and neck. In countless personal statements for residency, medical students have described their first experience seeing the facial nerve or a neck dissection as the pivotal moment they became interested in otolaryngology. It seems unlikely, but there is some truth to the statement, and mastery of this complicated part of the body is daunting, rewarding, and probably impossible.
THE BEST TOYS
Otolaryngology is a field that uses many cutting edge technologies. As a field that works in holes (ears, nose, throat), innovative techniques are necessary to operate in small places. These include lasers to excise lesions in the airway, drills to perform mastoid surgery, titanium prostheses to reconstruct the ossicles of the middle ear, cochlear implants, bone-anchored hearing aids, endoscopes to examine and operate on the aerodigestive tract and sinuses/skull base, microdebriders to destroy polyps, plates and screws for reconstruction of the facial skeleton, and an emerging use of robotics. For those with and without an engineering background, there are many gadgets to apply creatively.
There are countless jokes centered on the unique stereotypes labeled to physicians within various medical and surgical fields. And while these traits are often extremely exaggerated and over simplistic, it is true that people of similar personalities tend to find themselves gravitating toward certain specialties.
While there are obviously exceptions and diverse personalities within the field, for whatever reason, otolaryngology has traditionally attracted “nice people”. With running the risk of over generalizing, otolaryngologists tend to break the “malignant surgeon” stereotype and in general, they are easy-going, satisfied people who can just as easily talk about last night's baseball game as they can describe a radical neck dissection. Even within the medical literature, the otolaryngologist has been referred to as “the mild mannered otolaryngologist”, while in some programs they are known as the “gentlemen (or gentlewomen) surgeons.” One urologist colleague with whom I trained as an intern would tell medical students that they should go into urology because “urologists were some of the happiest doctors, second only to otolaryngologists!” This may seem far-fetched and ridiculous, but like attracts like. If you’re a nice, hard-working person who enjoys surgery, then the profession of otolaryngology wants you!
INTERESTING RESEARCH OPPORTUNITIES
Research has always been an important part of otolaryngology. As a field that deals with many of the body’s senses (taste, hearing, smell, touch, and sometimes vision), there are many interesting research avenues. Most residency programs provide at least one 4 month research block, while others offer 1 or even 2 years of research. For those with a neuroscience background, the auditory system, and nerve regeneration are excellent areas to research. For engineers, cochlear implants (and soon vestibular implants) are an excellent outlet for your skills. For those with a more molecular angle, head and neck cancer and hair cell death and regeneration may be your niche. For those who despise anything involving a protein, mouse, circuit, or computer programming, there are boundless clinical research opportunities. Some residency programs even offer an MPH during residency training.
Lots of people have heard jokes regarding the ENT lifestyle: ENT stands for “early nights and tennis” or “easy not tough”. While these statements are obviously embellished, the field of otolaryngology does lend to a better lifestyle than many other surgical fields. Many of the procedures performed by the otolaryngologist can be completed on an outpatient basis, and with the exception of patients with advanced oncologic disease, the majority of patients who do get admitted to the hospital are generally healthy and have relatively short, uneventful hospital stays.
According to a 2002 report by the American Medical Association, Otolaryngologists averaged approximately 52 hours of patient care per week compared to roughly 60hrs/wk for general surgery, orthopedic surgery, and neurosurgery and 56hrs/wk for urology and plastic surgery. The average annual compensation for practitioners in the field is between 250-300k, but can vary widely depending on fellowship training, local geographic demand and whether one is primarily in an academic or private practice setting.
As previously mentioned, otolaryngologists are truly trained to be both medical and surgical specialists. Because the surgical portion tends to be more grueling with early mornings and less schedule predictability, it is not uncommon for many otolaryngologists later in their career to change to solely clinic based practices allowing for increased career longevity as desired.
Finally, when discussing life-style considerations the topic of supply must be discussed. The number of resident positions for otolaryngology – head and neck surgery is strictly guarded so that the field does not become over-saturated. While all surgical specialties physicians tend to disproportionately congregate in larger urban areas, currently the number of positions exceeds the number of active otolaryngologists guaranteeing all newly graduated residents great marketability with very little geographic restriction when searching for employment.
PHLEGM, EARWAX, SNOT, & PROJECTILE TRACH SECRETIONS
Most people in the medical field would find this entry funny, but there are some people who absolutely cannot stand being around the various secretions of the head and neck – for these individuals, otolaryngology is probably not the best fit. Obviously, all surgical (and most medical) fields deal with some sort of bodily fluids. You just have to decide which you are most ok with.